The Total Joint Navigator coordinates care and services across the continuum of care by reviewing the utilization of hospitalized days and services for in-patient acute stays, and managing the post-acute stay to prevent avoidable readmissions and improve the quality of care. This individual will be responsible for building relationships with DCH partners across all settings to promote use of evidence-based best practices and efficient methodologies to provide safe, quality care across the health care continuum for the DCH patient.

1. Completes a screen of all assigned/appropriate patients to establish a preliminary acute discharge plan, coordinates post-operative care across the continuum to assure key outcomes are achieved.
2. Provides education to patients, and significant others in a pre-operative class setting and throughout the hospital experience.
3. Works collaboratively with patients, physicians, hospital discharge planning staff, care management, nursing, rehabilitation and post-acute providers to achieve desired patient outcomes, such as post-operative complications, service excellence, length of stay, and readmissions, through cost-effective use of healthcare resources.
4. Participates in hospital unit rounds to ensure that patients are meeting key recovery outcomes and develops a plan of care for each patient’s physical, mental, and social needs based on an ongoing clinical assessment.
5. Works closely with the case manager to coordinate the care between acute and post-acute providers using protocols, timelines and standardized physician orders and other mechanisms to assure optimal patient outcomes.
6. Acts as a patient advocate to ensure that the care experience is patient and family-centered.
7. Maintains a close working relationship with the community and hospital physicians and hospital leaders and community contacts.
8. Collaborates and problem solves with the key members of the care team and steering committees to determine key barriers or obstacles for recovery. 
9. Maintains patient contact (phone or in-person) post-discharge utilizing a risk assessment to determine when interventions are needed.
10. Other duties as assigned.

Education and Professionalism

1. Serves as a resource to patients, physicians, nursing, leadership and other disciplines
2. Maintains patient and staff confidentiality.
3. Utilizes effective written and verbal communication methods.
4. Establishes and maintains working relationships with surgeons, nursing, case management and community providers.
5. Requires effective written and verbal communication skills.
6. Must be capable of working effectively with a diverse group of physicians and providers.
7. Must possess group teaching and education skills.
8. Requires demonstrated ability to work independently, requiring little direct supervision.  

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

RN with BSN, MSN preferred and State of Alabama registered nurse licensure with at least two years of care management, community outreach, or public health experience preferred.

                                                                          Or

Social Worker, LMSW or LCSW preferred with State of Alabama licensure with at least two years of care management, community outreach, or public health experience preferred.

Skill in using Microsoft office applications, and Information systems including but not limited to MIDAS.

Demonstrated critical thinking skills and ability to prioritize work load.

Ability to exercise clinical judgment and autonomous decision making.

Strong interpersonal skills relative to both professional and lay interactions.

Strong organizational skills.

Demonstrated working knowledge of performance improvement activities.

Demonstrated working knowledge of data management/reporting practices.

Strong communication skills. Must be able to read, write legibly, speak and comprehend English.

SCOPE, PURPOSE AND FREQUENCY OF CONTACTS:

On-going contact with patient and families, medical-dental staff, social workers, nursing PI/Outcomes, and ancillary services. Additional contact with home health care providers, durable medical equipment providers, insurance /managed care organizations and varied community resources.  It may require ability to travel to off-site locations.

WORKING CONDITIONS

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

PHYSICAL FACTORS

Physical

• Able to lift at least 20 lbs and transporting of patient education materials, audiovisual aids (flip-charts; overhead projector, etc.) and therapy equipment (walkers, crutches, exercise supplies, etc.)
• Ability to tolerate prolonged periods of sitting, or standing and/or walking
• Ability to reach reasonable distances to handle equipment
• Good manual and finger dexterity
• Good communication skills
• Able to perform the duties with or without reasonable accommodation
• Hearing and vision must be normal or corrected to within normal range. 

Psychological

Includes demonstrating leadership skills, delegating to team members, addressing conflict, communicating with all types of personalities, and being responsible for outcomes/results.